Review of "Law, Liberty, and Psychiatry"

Thomas Szasz
has written more than a dozen books, most of them elaborations on the
fundamental themes of his first major work, The Myth of Mental Illness
(1961). That book became the intellectual basis for the phenomenon of
"anti-psychiatry," which functioned both as an intellectual challenge
to psychiatry's claims to scientific and medical credibility, and as the animus
for a political movement aiming to oppose the power of psychiatrists and defend
the rights of "psychiatrized" persons.

Two years
after publishing The Myth of Mental Illness, Szasz followed it up with Law,
Liberty, and Psychiatry. His earlier attack on the concept
of mental illness is reiterated and extended in the sequel, but the relative
emphasis now shifts from the status of mental illness as a supposed medical
notion to the status of psychiatric claims as a basis for legal
decision-making. In this more ethically and politically focused work, Szasz
sets his sights on three major targets: first, as before, the very idea of
mental illness; second, the use of that idea to authorize specific forms of
legal or quasi-legal coercion and regulation, notably involuntary commitment;
and third, the coalescence of psychiatry and other ostensible helping
professions, supported by misguided judges and legislators, into a rising
"therapeutic state," animated by "a spirit of do-goodism"
(240), but posing a grave threat to the rule of law and the liberal traditions
of constitutional liberty.

None of these concerns seems entirely groundless,
but it is worth subjecting each one individually to critical scrutiny.

Mental
Illness. On this question, Szasz certainly can't be faulted for
fence-sitting, bluntly stating that "mental illnesses do not exist"
(16). But we may wonder whether "existence" is quite the right
concept for framing the question he intends to address. In particular, he
concedes three points which, taken together, cast doubt on this approach.
First, he admits that "the social and psychological occurrences so
labeled" (as mental illness) do indeed exist (16). Second, he
acknowledges that, like mental illness, "bodily" illness is a normative
notion, implying deviation from some favored standard, although in the case
of bodily but not mental illness the favored standard and the deviation from it
"can be stated in anatomical and physiological terms" (14). Third,
he concedes that finding oneself labeled as mentally ill, precisely because one
deviates from a (non-anatomical, non-physiological) norm can have enormous
implications for how one sees oneself, how one is seen by others, how one will
be treated in the legal system, and so on. At this point, the reader will be
led to wonder how much sense it makes to say that mental illness "does not
exist" when we know that norm-violating behavior exists, the practice of
labeling such behavior as mentally ill exists, and there follows upon such
labeling a series of psychological, administrative, legal and interpersonal
implications  which are only too real  concerning how one is treated and how
one relates to oneself? Surely, Szasz is operating with an unnecessarily
impoverished notion of existence here. Perhaps he means (or should mean) to
say something different, such as that facts about mental illness  unlike facts
about bodily illness (including "neurological deficits," which Szasz
accepts as a genuinely medical notion, on p. 12)  are institutional
facts, i.e., facts about a social status that is conferred on some people by
members of a community (a status with specific implications for
role-expectations and typical role-performances) rather than "brute
facts" about the physical world. He could certainly claim, as one might
nowadays put it, that mental illnesses are "socially constructed" in
ways that the bodily illnesses addressed by what Szasz calls "medicine
proper" are not. This claim would be easier to defend, and would not
require Szasz to retreat from his ambitious political project of denying
psychiatry access to the credibility and authority it derives from its
"essentially misleading association with the practice of medicine" of
the usual, non-psychiatric sort (23). No doubt there is, as Talcott Parsons
suggested, a normative "sick role" for cancer patients or amputees;
but  so one could argue  the identification of someone as having a
Narcissistic Personality Disorder is really nothing morethan a
role-assignment effected by the imposition of a particular social status on a
patient by psychiatric authorities. In any case, this is a line of thinking
that Szasz did not pursue.

Coercion.
Nietzsche points out that a society ruled by priests needs sin, because sin is
the "handle" and foothold for power. Szasz makes similar points
about the function of mental illness for psychiatry. The application of the
"mental illness" label has the function of authorizing intrusions and
coercions of various kinds, but in this book Szasz is primarily interested in
one kind of intervention: involuntary commitment of the mentally ill to
hospitals. According to Szasz, the fact that this phenomenon is widely thought
to be tolerable, even in countries with liberal legal systems, arises out of
two unquestioned but plainly mistaken presuppositions. First, there is the
assumption that many people labeled as "mentally ill" are not
responsible for their actions. And second, there is the tendency to regard the
psychiatrist/patient relationship as non-adversarial. The first assumption
often necessitates finding a proxy decision-maker; the second assumption makes
it natural that the physician should be invited to assume that role, alone or
in concert with others. Szasz tries to challenge both assumptions. Unfortunately,
his case against the notion of non-responsibility "by reason of
insanity" seems to rest almost entirely on his ability to cite several
cases where the notion was in fact applied, but clearly shouldn't have been 
an objection that unintentionally invites readers to insist on a more rigorous
and careful application of a principle that Szasz would rather have them
discard altogether. By contrast, his case for dropping the assumption that
psychiatrists are primarily advocates for the best interests of their patients,
as opposed to advocates for the maintenance of social order (embodied in moral
opinions about what kinds of behavior are "healthy"), seems
essentially airtight. Above all, the notion that commitment, when demanded by
a psychiatrist, should be presumptively taken to be in the patient's best
interests, is here subjected to a withering and utterly convincing critique.

The
Therapeutic State. For many readers, the least appealing aspect of Law,
Liberty, and Psychiatry will be the association of Szasz's critical
insights about psychiatry as a mode of social control (which often anticipate
Michel Foucault's nominalist genealogies of "subjection" through
identification) with a specifically "libertarian" approach to
questions of political morality. Libertarians (most famously, Robert Nozick
and Milton Friedman) tend to reduce political questions to questions about what
should be done with property, whether property in one's person or one's resources,
and then to assume that questions of that kind should generally be referred to
the private preferences of the relevant property-holders taken individually.
For Szasz, accordingly, the basic moral objection to psychiatry in particular,
and to the therapeutic state in general, is that it usurps the function of
self-ownership from individuals. Szasz draws attention to the plain fact that
the demands made on the state, or made by the state, have expanded into
previously private realms, such as helping citizens reach their full potential,
relieving their suffering, and protecting them from misfortunes. In the face
of this development, Szasz, like other libertarians, worries about the price
that will have to be paid in personal liberty for every advance in social
welfare. "If...the state assumes the roles of parent and therapist, the
citizens will be forced to assume the complementary roles of child and patient.
This is bound to lead to the parentification of the government, and the
infantilization of the governed" (222). Of course, obvious objections
will arise from other locations on the political spectrum. How beneficial is
liberty from state paternalism to a person whose behavioral idiosyncrasies (for
lack of a better word) make sustained gainful employment unlikely indeed? To
be sure, infantilization at the hands of the state is not an appealing
solution, but neither is abandonment to a libertarian labor market. One reason
for the rise of the so-called therapeutic state is that markets "fail,"
in the sense that they produce victims. A libertarian like Szasz can accept
such market failures for the sake of preserving liberty and maintaining the
institutional basis for a society founded (he thinks) on respect for individual
persons. But most of us will continue to find in libertarianism a simplistic
and one-dimensional understanding of what it means to treat a person with
dignity, with dubious appeal as a positive alternative to psychiatric or state
paternalism, even when we agree with Szasz's critical objections to them.

But it is the
latter, the "negative" side of Szasz's work, as a fundamental
challenge to what others regard as obvious, that makes Law, Liberty, and
Psychiatry worthy of serious attention, even four decades after its
original publication.